Precertification Lists Results

CPT® Codes Searched:

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This procedure is listed on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List and may require precertification for Medicare Advantage plans only. If you are a registered user with our secure provider website, click here to submit the precertification request electronically: secure provider website. You can also utilize your current electronic solutions to submit a precertification request or call the number listed on the member's ID card. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified.

Note: If your request is for a drug that requires precertification and you are a registered NaviNet user, please use the Drug Authorizations online form. The form can be found on the NaviNet home page under Services.

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Effective 06/01/17, this procedure is listed on the Aetna Participating Provider Precertification List. Precertification is required for Medicare Advantage members after the 60th consecutive day of treatment. Precertification is not required for members enrolled in commercial plans. If you are a registered NaviNet user, you can submit the precertification request electronically.

You also can utilize your current electronic solutions to submit a precertification request or call the number listed on the member's ID card. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified.

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Precertification for this procedure may be required through a delegated organization for members in selected states.

Check below for the appropriate contact information. Precertification may not apply to all areas or products available within the state. Please contact the vendor for details.

Special situations

Type of network/state

Precertification requirement

IPA/PMG

See footnote below

Member is in a Rental/Passive Network

No precert required

If vendor states "We do not handle precertification for this member"

No precert required

Non Participating.....

If you are a non-participating physician, hospital or other health professional, call the number on the member's ID card for precertification requirements

State not Found on Listing

No precertification is required; however, this code may not be eligible for coverage under the member's plan.

**IPA/PMG Affiliated Physicians: The processes for referral, precertification, and laboratory and radiology services for providers participating in Aetna through their affiliation with an Independent Practice Association (IPA) or Physician Medical Group (PMG) may differ from those outlined here. In some cases, patients must obtain ob/gyn-related services from a provider affiliated with their PCP's IPA/PMG. IPA/PMG affiliations generally affect administration of the following plans: HMO (including Open Access), POS (including USAccess) and Aetna HealthFund. Please contact your IPA/PMG administrator for details.

***Rental and Passive network providers are excluded from the program. Therefore, precertification is not needed in these markets/for these providers.

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For Connecticut members, the procedure code you entered requires medical review when services are rendered on an outpatient basis. Please contact Orthonet at 1-800-771-3205 for further instructions. Do not submit a precertification request to Aetna.

For Delaware, New York, Pennsylvania, and West Virginia members, the code you entered requires medical review when services are rendered on an outpatient basis. Please contact National Imaging Associates at 1-866-842-1542 for further instructions. Do not submit a precertification request to Aetna.

For all other states, this procedure was not found on the Aetna Participating Provider Precertification List; therefore, no precertification is required. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified. Please call the number listed on the member's ID card.

CPT® Code [param-placeholder]

For Delaware, New York, Pennsylvania, and West Virginia members, the code you entered requires medical review when services are rendered on an outpatient basis. Please contact National Imaging Associates at 1-866-842-1542 for further instructions. Do not submit a precertification request to Aetna.

For all other states, this procedure was not found on the Aetna Participating Provider Precertification List; therefore, no precertification is required. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified. Please call the number listed on the member's ID card.

CPT® Code [param-placeholder]

The code you entered requires medical review for members in Connecticut when services are rendered on an outpatient basis. Please contact Orthonet at 1-800-771-3205 for further instructions. Do not submit a precertification request to Aetna.

For all other states, this procedure was not found on the Aetna Participating Provider Precertification List; therefore, no precertification is required. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified. Please call the number listed on the member's ID card.

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The code you entered requires Medical Review through a special program. To expedite your request, fax the Specialty Medication Form to 1-888-267-3277. You may also call 1-866-503-0857 to speak with a representative. Do not submit your precertification request to the Aetna Medical Precertification area. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified. Please call the number listed on the member's ID card.

Note: If your request is for a drug that requires precertification and you are a registered NaviNet user; please use the Drug Authorizations online form. The form can be found on the NaviNet home page under Services.

CPT® Code [param-placeholder]

This procedure is listed on the Aetna Participating Provider Precertification List. Precertification is required for members with a commercial plan; precertification may be required for Medicare Advantage members. You can utilize your current electronic solutions to submit a precertification request or contact Aetna Women’s Health/Aetna Infertility Department at 1-800-575-5999. If you are a nonparticipating physician, hospital or other health care professional, the member’s plan may require that these services be precertified.

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The code you entered requires medical review by Aetna Women's Health/BRCA Genetic Testing Program. Please call 1-877-794-8720 for further instructions. If you are a nonparticipating physician, hospital or other health care professional, the member’s plan may require that these services be precertified.

CPT® Code [param-placeholder]

The code you entered requires precertification through Aetna's National Medical Excellence program for all major organ transplant evaluations including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose chemotherapy. Please call 1-877-212-8811 for further precertification instructions.

If this service is not transplant related, precertification is required for members with a commercial plan; precertification may be required for Medicare Advantage members. If you are a registered user with NaviNet, you can submit the precertification request electronically. You can also utilize your current electronic solutions to submit a precertification request or call the number listed on the member's ID card. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified.

**IPA/PMG Affiliated Physicians: The processes for referral, precertification, and laboratory and radiology services for providers participating in Aetna through their affiliation with an Independent Practice Association (IPA) or Physician Medical Group (PMG) may differ from those outlined here. In some cases, patients must obtain ob/gyn-related services from a provider affiliated with their PCP's IPA/PMG. IPA/PMG affiliations generally affect administration of the following plans: HMO (including Open Access), POS (including USAccess) and Aetna HealthFund. Please contact your IPA/PMG administrator for details.

***Rental and Passive network providers are excluded from the program. Therefore, precertification is not needed in these markets/for these providers.

CPT® Code [param-placeholder]

Precertification for this procedure may be required through a delegated organization for members in selected states.

Check below for the appropriate contact information. Precertification may not apply to all areas or products available within the state. Please contact the vendor for details.

Special situations

Type of network/state

Precertification requirement

IPA/PMG

See footnote below

Member is in a Rental/Passive Network

No precert required

If vendor states "We do not handle precertification for this member"

No precert required

Non Participating.....

If you are a non-participating physician, hospital or other health professional, call the number on the member's ID card for precertification requirements

State not Found on Listing

No precertification is required; however, this code may not be eligible for coverage under the member's plan.

**IPA/PMG Affiliated Physicians: The processes for referral, precertification, and laboratory and radiology services for providers participating in Aetna through their affiliation with an Independent Practice Association (IPA) or Physician Medical Group (PMG) may differ from those outlined here. In some cases, patients must obtain ob/gyn-related services from a provider affiliated with their PCP's IPA/PMG. IPA/PMG affiliations generally affect administration of the following plans: HMO (including Open Access), POS (including USAccess) and Aetna HealthFund. Please contact your IPA/PMG administrator for details.

***Rental and Passive network providers are excluded from the program. Therefore, precertification is not needed in these markets/for these providers.

CPT® Code [param-placeholder]

This procedure is listed on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List. Precertification is required for members with a commercial plan; precertification may be required for Medicare Advantage members. If you are a registered user with our secure provider website, click here to submit the precertification request electronically: secure provider website. You can also utilize your current electronic solutions to submit a precertification request or call the number listed on the member's ID card. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified.

Note: If your request is for a drug that requires precertification and you are a registered NaviNet user, please use the Drug Authorizations online form. The form can be found on the NaviNet home page under Services.

You also can utilize your current electronic solutions to submit a precertification request or call the number listed on the member's ID card. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified.

CPT® Code [param-placeholder]

The code you entered requires medical review with Oncology Pathway Solutions for chemotherapy for cancer diagnosis.

Precertification is required for all members ages 18 years or older when performed in a physician’s office (medical oncologist or hematologist only), outpatient hospital, or ambulatory facility (outpatient infusion center\facility) for members in the following states:

For all other states, this procedure was not found on the Aetna Participating Provider Precertification List; therefore, no precertification is required. If you are a nonparticipating physician, hospital or other health care professional, the member's plan may require that these services be precertified. Please call the number listed on the member's ID card.

CPT® Code [param-placeholder]

Precertification for this procedure may be required through a delegated organization for members in selected states.

Check below for the appropriate contact information. Precertification may not apply to all areas or products available within the state. Please contact the vendor for details.

Special situations

Type of network/state

Precertification requirement

IPA/PMG

See footnote below

Member is in a Rental/Passive Network

No precert required

If vendor states "We do not handle precertification for this member"

No precert required

Non Participating.....

If you are a non-participating physician, hospital or other health professional, call the number on the member's ID card for precertification requirements.

**IPA/PMG Affiliated Physicians: The processes for referral, precertification, and laboratory and radiology services for providers participating in Aetna through their affiliation with an Independent Practice Association (IPA) or Physician Medical Group (PMG) may differ from those outlined here. In some cases, patients must obtain ob/gyn-related services from a provider affiliated with their PCP's IPA/PMG. IPA/PMG affiliations generally affect administration of the following plans: HMO (including Open Access), POS (including USAccess) and Aetna HealthFund. Please contact your IPA/PMG administrator for details.

***Rental and Passive network providers are excluded from the program. Therefore, precertification is not needed in these markets/for these providers.

CPT® Code [param-placeholder]

The procedure code you entered was not found on the Aetna Participating Provider Medical Precertification List. If you’re a participating provider, no precertification is required when this service is performed as an outpatient procedure for a medical or surgical diagnosis. This procedure code may require precertification for behavioral health diagnoses.

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Precertification Lists

Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".

The term precertification here means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.

All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search."

The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT®), copyright 2018 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

The responsibility for the content of Aetna Precertification Code Search Tool is with Aetna and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in Aetna Precertification Code Search Tool. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Aetna Precertification Code Search Tool should refer to the most Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")

CPT only copyright 2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. You, your employees and agents are authorized to use CPT only as contained in Aetna Precertification Code Search Tool solely for your own personal use in directly participating in health care programs administered by Aetna, Inc. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to sue CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.ama-assn.org/go/cpt.

U.S. Government Rights
This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

Disclaimer of Warranties and Liabilities.
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with Aetna, Inc. and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".

The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.

This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.